Healthcare Provider Details

I. General information

NPI: 1053268508
Provider Name (Legal Business Name): MICHIGAN INSTITUTE OF UROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29275 NORTHWESTERN HWY STE 120
SOUTHFIELD MI
48034-1044
US

IV. Provider business mailing address

20952 E 12 MILE RD STE 200
SAINT CLAIR SHORES MI
48081-3203
US

V. Phone/Fax

Practice location:
  • Phone: 586-771-4820
  • Fax:
Mailing address:
  • Phone: 586-771-4820
  • Fax: 586-771-7960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY LEE MCAULEY
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 586-771-4820